Provider Demographics
NPI:1912911561
Name:MAYO CLINIC HEALTH SYSTEM - PHARMACY & HOME MEDICAL INC
Entity Type:Organization
Organization Name:MAYO CLINIC HEALTH SYSTEM - PHARMACY & HOME MEDICAL INC
Other - Org Name:NORTHWEST HEALTH VENTURES INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-838-5270
Mailing Address - Street 1:PO BOX 88
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54702-0088
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13025 8TH ST
Practice Address - Street 2:SUITE PHM # 1
Practice Address - City:OSSEO
Practice Address - State:WI
Practice Address - Zip Code:54758-7634
Practice Address - Country:US
Practice Address - Phone:715-597-3166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAYO CLINIC HEALTH SYSTEM - PHARMACY & HOME MEDICAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7330332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
51 21645OtherNCPDP
WI33194100Medicaid
WI33194100Medicaid
WI0408270003Medicare NSC